key: cord-0780472-czzrfl7k
authors: Mori, Makoto; Geirsson, Arnar; Vallabhajosyula, Prashanth; Assi, Roland
title: Surgical management of thoracic aortic emergency with pre‐ and postoperative COVID‐19 disease
date: 2020-07-15
journal: J Card Surg
DOI: 10.1111/jocs.14865
sha: 3281a70f8717da582532f2c58db914931e141bed
doc_id: 780472
cord_uid: czzrfl7k

The nuance of operative decision making for those in need of emergent operation during coronavirus disease 2019 (COVID‐19) pandemic is increasingly complex in the absence of robust data or guidelines. We present two cases of thoracic aortic emergencies with COVID‐19 disease who survived high‐risk operations to highlight the potential for successful outcomes even in situations compounding patient disease, morbid operation, and the added risk associated with virulent disease in the pandemic time.

Even with the abrupt decline in the number of patients presenting with acute conditions during the coronavirus disease 2019 (COVID-19) pandemic, 1 the sickest and the most acute patients continue to require appropriate care, including high-risk operations.

Given the morbidity of the operation now compounded with the risk of contracting or suffering from the highly virulent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the postoperative vulnerable period, the operative decision making has become all the more complex, 2 with one existing report of a patient with acute type A dissection and COVID-19 disease resulting in operative mortality. 3 We encountered two cases of surgical thoracic aortic emergencies, one undergoing an operation with known COVID-19 positive status and another undergoing an operation and contracted COVID-19 in the postoperative period. Both patients survived and recovered well to demonstrate the potential value in pursuing aggressive surgical treatment even in the nuanced context of increased postoperative risk of succumbing to this lethal COVID-19 disease.

The first patient is a 54-year-old man who was otherwise without comorbidity who presented with a sudden onset chest pain and found to have intramural hematoma involving the aortic root and ascending aorta on computed tomography (CT) (Figure 1 ). The patient had a family history of thoracic aortic aneurysm and dissection. Following the bypass grafting, he had normal biventricular function and came off cardiopulmonary bypass easily. The recovery course was uneventful, the aortic valve was competent without any leak with mean gradient of 6mm Hg on postoperative echocardiography.

The patient was discharged to home on postoperative day 6.

Postoperative CT angiogram showed intact surgical repair without any residual dissection.

The second patient is an 82-year-old woman with history of paroxysmal atrial fibrillation, diastolic heart failure, chronic obstructive pulmonary disease on steroids, and pacemaker for sick sinus syndrome, who presented with sudden onset chest pain and facial weakness, anuria and acute kidney injury, and found to have acute type A aortic Operative decision making is nuanced in the pandemic era, as the current decision models for elective operations 5 and known risk factors for mortality 6 may not readily apply to cardiac surgical patients undergoing emergent operations. Logistically, it may be important for hospitals to dedicate a cardiac surgery operating room equipped with negative pressure for patients with COVID-19 to facilitate timely operations while the SARS-CoV-2 diagnostic test is processed.

Although COVID-19 is highly morbid, extremely high-risk operations such as extensive aortic repair for thoracic aortic emergencies may have successful outcomes, even in an elderly contracting COVID-19 in the morbid postoperative recovery period. In the absence of strong evidence or guidelines in these nuanced situations, our report may provide important examples that these challenging operations could yield successful results.

Reduced rate of hospital admissions for ACS during Covid-19 outbreak in Northern Italy

The untold toll-the pandemic's effects on patients without Covid-19

El-Dalati S Acute type A aortic dissection during COVID-19 outbreak

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

The use of decision modelling to inform timely policy decisions on cardiac resource capacity during the COVID-19 pandemic

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Surgical management of thoracic aortic emergency with pre-and postoperative COVID-19 disease

The authors declare that there are no conflict of interests.

http://orcid.org/0000-0002-2367-8354Arnar Geirsson http://orcid.org/0000-0002-8943-9962Prashanth Vallabhajosyula http://orcid.org/0000-0002-1192-3367Roland Assi https://orcid.org/0000-0002-0863-9867